Hitz Memorial Home

In the surveyor’s words

From the most serious findings on record at Hitz Memorial Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to conduct thorough investigations for allegations of sexual abuse and failed to protect a resident during active investigations for 1 (R42) of 1 resident reviewed for abuse in the sample of 26. This failure resulted in R42 being vulnerable with no protective measures from future potential abuse implemented. R42 subsequently was subjected to additional abuse allegations, by V17 (family member) on 1/2/25, 7/17/25 and 2 not dated allegations from December 2025. A reasonable person would expect to be free of abuse, and protected from further allegations of abuse. Following these circumstances, a reasonable person would potentially experience severe psychological harm with feeling shame, guilt, anger, and embarrassment. […]

• Actual harm, patternF888Sep 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure staff are vaccinated for COVID-19. The facility failed to develop a policy that includes a process for ensuring staff are vaccinated for COVID-19, medical or religious exemptions, and a contingency plan for staff who are not vaccinated and do not have an exemption or temporary delay. This has the potential to affect all 40 residents in the facility. Findings include: On 9/6/22 at 8:00 AM, upon entry to the facility there was a sign on Facility's Visitor Entrance door that read, We are COVID positive at this time. […]

• Actual harm, isolatedF600Sep 12, 2024

  Based on interview and record review, the Facility failed to prevent verbal and physical abuse and neglected to accurately assess a resident for injury prior to initiating a transfer for 1 of 2 residents (R99) reviewed for abuse/neglect in the sample of 25. This failure caused R99 to experience fear and increased anxiety and unknown potential further injury. Findings include: R99's Facesheet dated 9/11/2024 documents R99 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to; osteoporosis, anxiety and post traumatic stress disorder. R99's Progress Notes dated 7/7/2024 documents R99 was attempting to self transfer out of her recliner, in her room and fell to the floor. It further documents R99 began complaining of right hip pain. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based on observation, interview, and record review, the Facility failed to store food in a manner that prevents foodborne illness. This has the potential to affect all 43 residents living in the Facility.Findings include: On 3/3/26 at 7:58 AM, the standing refrigerator held three containers of an orange gelatinous substance labeled with R28's last name. The containers were not dated or labeled with the contents inside. V6, Cook, looked at a form labeled Audit: Food/Beverages Brought into the Facility and stated the containers were R28's orange tapioca gelatin and were placed in the refrigerator on 2/22/26. There was also a clear plastic cup containing brown liquid from a retail coffee establishment that was not labeled or dated. […]

• No harm, potential for more than minimal, widespreadF880Mar 12, 2026

  Based on interview and record review, the Facility failed to monitor infection trends and follow infection control procedures in the Facility. This has the potential to affect all 43 residents living in the Facility.Findings include: 1-The Facility's Infection Control Log does not list a causative organism for R2's 8/29/25 UTI (Urinary Tract Infection). The Facility's Infection Control Log does not list a causative organism for R39's 10/29/25 UTI. The Facility's Infection Control Log does not list a causative organism for R6's 11/7/25 UTI. The Facility's Infection Control Log does not list a causative organism for R27's 11/10/25 UTI. […]